Arthropathy, quality of life, depression, and anxiety in Behcet's disease: relationship between arthritis and these factors

Thoughts and Experiences of Behçet Disease From Participants on a Reddit Subforum: Qualitative Online Community Analysis

BACKGROUND

Behçet disease (BD) is a type of vasculitis with relapsing episodes and multisystemic clinical features, associated with significant morbidity and impact on patients' lives. People affected by BD often participate in discussions of their illness experiences. In-person support groups have limited physical accessibility and a relative lack of anonymity; however, online communities have become increasingly popular.

OBJECTIVE

This study investigates the perspectives and experiences of people affected by BD by examining the content shared and discussed on a subforum of the website Reddit-a popular online space for anonymous discussions.

METHODS

All discussion threads posted between March 9, 2021, and March 12, 2022, including posts and comments, were examined from the subforum "r/Behcets," an anonymous online community of 1100 members as of March 2022. A Grounded Theory analysis was completed to identify themes and subthemes, and notable quotes were extracted from the threads. Parameters extracted from each post included the number of comments, net upvotes, category, and subcategories. Two research team members read the posts separately to identify initial codes and themes to ensure data saturation was achieved.

RESULTS

Six recurring themes were identified: (1) finding connectedness and perspectives through shared experiences, (2) struggles of the diagnostic odyssey, (3) sharing or inquiring about symptoms, (4) expressing strong emotions relating to the experience of BD, (5) the impact of BD on quality of life and personal relationships, as well as (6) COVID-19 and the COVID-19 vaccination in relation to BD. Subthemes within each theme were also identified and explored.

CONCLUSIONS

This novel study provides a qualitative exploration of the perspectives and experiences of people affected by BD, shared in the anonymous and accessible online community of Reddit. The study found that people impacted by an illness seek to connect and receive validation through shared conditions and experiences. By examining the content shared in r/Behcets, this study highlights the needs of people affected by BD, identifying gaps and areas for improvement in the in-person support they receive.

EULAR study group on ‘MHC-I-opathy’: identifying disease-overarching mechanisms across disciplines and borders

The ‘MHC-I (major histocompatibility complex class I)-opathy’ concept describes a family of inflammatory conditions with overlapping clinical manifestations and a strong genetic link to the MHC-I antigen presentation pathway. Classical MHC-I-opathies such as spondyloarthritis, Behçet’s disease, psoriasis and birdshot uveitis are widely recognised for their strong association with certain MHC-I alleles and gene variants of the antigen processing aminopeptidases ERAP1 and ERAP2 that implicates altered MHC-I peptide presentation to CD8+T cells in the pathogenesis. Progress in understanding the cause and treatment of these disorders is hampered by patient phenotypic heterogeneity and lack of systematic investigation of the MHC-I pathway.

Here, we discuss new insights into the biology of MHC-I-opathies that strongly advocate for disease-overarching and integrated molecular and clinical investigation to decipher underlying disease mechanisms. Because this requires transformative multidisciplinary collaboration, we introduce the EULAR study group on MHC-I-opathies to unite clinical expertise in rheumatology, dermatology and ophthalmology, with fundamental and translational researchers from multiple disciplines such as immunology, genomics and proteomics, alongside patient partners. We prioritise standardisation of disease phenotypes and scientific nomenclature and propose interdisciplinary genetic and translational studies to exploit emerging therapeutic strategies to understand MHC-I-mediated disease mechanisms. These collaborative efforts are required to address outstanding questions in the etiopathogenesis of MHC-I-opathies towards improving patient treatment and prognostication.

A review of patient-reported outcome measures used in uveitis

We review patient-reported outcome measures (PROMs) used to evaluate the quality of life (QoL) in uveitis and provide a quality assessment of the psychometric properties of the PROMs, making it easier to choose the best questionnaire for uveitis. Our review included 158 articles. A total of 98 PROMs were used to measure QoL in uveitis and the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ -25) was the most frequently used PROM in these studies. There were 5 uveitis-specific PROMs, but they were meant for either birdshot choroidopathy or cytomegalovirus retinitis or paediatric uveitis. There are no PROMs developed explicitly for the more common, anterior uveitis, intermediate uveitis, panuveitis, and chronic uveitis. The uveitis-specific PROMs performed better in our quality assessment criteria compared to other PROMs. However, these PROMs were constructed using traditional classical test theory and have not been assessed using the modern family of psychometric assessment methods such as Rasch analysis. As new therapeutic modalities for uveitis such as the new biological agents and steroid implants, continue to evolve, a comprehensive PROM will be increasingly valued in clinical trial settings to compare the effects of treatments from the patient's perspective.

Behçet's Syndrome Apart From the Triple Symptom Complex: Vascular, Neurologic, Gastrointestinal, and Musculoskeletal Manifestations. A Mini Review

Behçet‘s Syndrome (BS) is a variable vessel vasculitis according to the Chapel Hill Consensus Nomenclature (1) and may thus affect any organ, including major and minor arterial and venous vessels to a varying degree and with varying frequency. Although the main features of BS are recurrent oral and genital aphthous ulcers, cutaneous lesions, ocular inflammation and arthritis—major vessel and life—or organ threatening involvement of internal organs and the central and peripheral nervous system occur. In general, BS in Europe appears to form six phenotypes of clinical manifestations (2), which are (1) mucocutaneous only, (2) predominant arthritis/articular involvement, (3) vascular phenotype, (4) ocular manifestations, which are most likely associated with CNS manifestations and HLA-B51, (5) dominant parenchymal CNS manifestations (being associated with the ocular ones), and (6) gastrointestinal involvement. Mucocutaneous manifestations are present in almost all patients/all phenotypes. In the following review, we summarize the current knowledge concerning vascular, neurologic, gastrointestinal and musculoskeletal manifestations of the disease.

Relationship of diffusion tensor imaging parameters with neurocognitive dysfunction in patients with Behcet's disease

Behcet's disease (BD) is a chronic, multisystemic, relapsing-remitting, progressive inflammatory disorder with unknown etiology. The aim of the study is to investigate the white matter integrity and subclinical brain parenchymal involvement in Behcet's subjects by utilizing diffusion tensor imaging (DTI) and to correlate apparent diffusion coefficient (ADC), fractional anisotropy (FA), mean diffusivity (MD), and radial diffusivity (RD) values measured from the diverse distinct anatomic locations with the disease duration time and neurocognitive function test results. Thirty-five adults with Behcet's disease and 21 age-matched healthy controls were enrolled in this study. Neurocognitive functions of the patients were evaluated with the Brief Repetable Battery-Neuropsychological tests (BRB-N). In both groups, DTI metrics were calculated from 19 different locations in the brain. The association between the DTI parameters and disease duration time and neurocognitive function test results were investigated. In Behcet's disease, at the cingulum and the splenium of the corpus callosum (SCC), FA values were significantly lower compared with the controls (p = 0.0015, p = 0.003, respectively). The ADC values of the corona radiata and RD values of superior longitudinal fasciculus and SCC were significantly higher than the controls (p = 0.023, p = 0.028, p = 0.006, respectively). Significant negative correlations were found between the FA values of cingulum, genu of corpus callosum (GCC), posterior limb of internal capsule (PLIC) and disease duration time (r = - 0.368; p = 0.029 and r = - 0.337; p = 0.048 and r = - 0.527; p = 0.001 respectively). All BD subjects performed significantly lower test scores on the spatial recall test (SPART) (p = 0.001). In addition, negative correlation was found between the MD values of the parietooccipital white matter and the selective reminding test (SRT) results (r = - 0.353; p = 0.037). Our DTI study presented microstructural alterations in the neurocognitive-related areas and BRB-N test results even in patients without neurological symptoms which may imply insidious neurological involvement.

Comparability of European League Against Rheumatology-Recommended Pharmacological Treatments of Oral Ulcers Associated with Behçet's Disease: A Systematic Literature Review of Randomized Controlled Trials

Objective

Oral ulcers are the cardinal manifestation in Behçet's disease (BD). The 2018 European League Against Rheumatism (EULAR) recommendations describe treatments for BD-associated oral ulcers with mucocutaneous involvement; however, little comparative effectiveness information for these agents is available. In the absence of head-to-head trials, an indirect treatment comparison (ITC) could provide useful evidence regarding comparative effectiveness of BD treatments. The purpose of this study was to conduct a comparative systematic literature review (SLR) and similarity assessment of randomized controlled trials (RCTs) investigating the oral ulcer-related efficacy outcomes of EULAR-recommended treatments for BD-associated oral ulcers to determine the feasibility of an ITC.

Methods

An SLR was performed to identify relevant RCTs indexed in MEDLINE/Embase before May 29, 2019. RCT similarities for the ITC were assessed based on a step-wise process recommended by the International Society for Pharmacoeconomics and Outcomes Research.

Results

In total, 317 articles were identified, of which 14 RCTs, reflecting 11 EULAR-recommended treatments, were evaluated in a similarity assessment. Number of oral ulcers, resolution of oral ulcers, and healing time for oral ulcers were identified as the possible oral ulcer-related outcomes. After completing the similarity assessment of these outcomes, it was determined that a robust ITC was infeasible for the three oral ulcer-related outcomes due to heterogeneity in outcomes reporting, study design, and/or patient characteristics. More broadly, the results underscore the need for and consistent use of standardized measures for oral ulcer outcomes to facilitate comparative research.

Conclusion

In the absence of head-to-head RCTs and infeasibility of quantitative ITC, comparative assessments for BD-associated oral ulcers are limited, including comparative effectiveness and cost-effectiveness evaluations. Healthcare decision-makers must continue to base treatment decisions on the extent and strength of available evidence (eg, robust RCTs), clinical guidelines, real-world experience, and patient considerations.

Quality of Life Assessment in Patients with Behçet's Disease using the Persian Version of the Leeds BD-QoL Questionnaire

Background:

Behçet’s disease (BD) can negatively impact the quality of life (QoL) of the affected patients. The present study aimed to assess the QoL of BD patients using the Leeds BD-QoL and compare its results with the WHOQOL-BREF questionnaire.

Methods:

In the present cross-sectional study, 179 BD patients and 304 healthy individuals (the control group) were recruited in Shiraz, 2017. The Persian version of the Leeds BD-QoL and WHOQOL-BREF questionnaires were used to assess the QoL of patients with BD. The QoL in the patient and control groups was compared after controlling the effect of some variables (age, sex, marital status, and educational level) using the multiple linear regression analysis. Spearman’s correlation coefficient was calculated for the Leeds BD-QoL and WHOQOL-BREF scores. Disease activity was measured using the Behçet’s Disease Current Activity Form. All the statistical analysis was performed using SPSS software (version 21.0). P<0.05 was considered statistically significant.

Results:

The mean of the Leeds BD-QoL total score in the patient group was 12.3±8.7. The control group had significantly higher scores in the WHOQOL-BREF total score and the physical health and psychological health domains compared with the patient group; mean difference of 10.24, 10.8, and 4.62, respectively (P<0.001). The Spearman’s correlation coefficient for the Leeds BD-QoL score and WHOQOL-BREF total score and its domains (physical health, psychological health, social relationships, and environment) was -0.669, -0.713, -0.714, -0.536, and -0.550, respectively. The disease activity score was correlated with the Leeds BD-QoL score (r=0.361, P<0.001).

Conclusion:

BD patients had a lower QoL than healthy individuals, specifically in the physical health and psychological health domains. An increase in disease activity and severity was associated with a reduced QoL. The Persian version of the Leeds BD-QoL questionnaire had an acceptable correlation with the WHOQOL-BREF questionnaire.

Illness Perception Mediates the Relationship Between the Severity of Symptoms and Perceived Health Status in Patients With Behçet Disease

OBJECTIVE

The aim of this study was to investigate the relationship between psychological representations of illness, perceived health status, and self-assessment of symptom severity in patients with Behçet disease, a rare long-term incurable condition with unclear etiology.

METHODS

Using cross-sectional survey design, data on self-administered questionnaires on illness perception, health status, symptoms severity, and demographic characteristics were collected from 273 patients with Behçet disease (age range, 18-65 years). The data were subjected to mediation analysis to test whether cognitive and emotional components of illness perception mediate the relationship between the severity of symptoms and heath status.

RESULTS

The results support our hypotheses that cognitive components of illness perception (perceived consequences and identity of the illness) mediate the link between symptom activity and pain, whereas emotional components of the illness (emotional representations about the illness) mediate the relationship between disease activity and perceived energy level.

CONCLUSIONS

The robustness of these mediation effects suggests potential directions for clinical psychologists and health care practitioners in developing support programs. We supplement our study with Open Access database containing information about type of medication, comorbid mood disorder, and detailed measurement of the severity of BD symptoms for sharing and accumulating multidisciplinary knowledge aiming to support the development of interventions. Addressing psychological aspects of BD will help to manage complex patients effectively.

Quality of Life in Patients With Behçet Disease and Its Relation With Clinical Symptoms and Disease Activity

BACKGROUND

Behçet's disease(BD) is a systemic vasculitis which may affect the quality of life (QoL).

AIMS

This study aimed to assess the QoL in Iranian Azeri BD patients as well as evaluating the association between QoL and disease characteristics including disease activity and clinical symptoms.

METHODS

In this cross-sectional study, a total of 123 BD patients aged 15-65 years fulfilling International Criteria for BD and 123 healthy controls matched with regard to gender were included. Patients aged 15-18 years had the informed consent and consent of their parents for participation. Short Form-36 Quality of Life Scale (SF-36) was used to evaluate QoL. Disease activity was measured by Behcet's Disease Current Activity Form and the Iranian Behcet's Disease Dynamic Activity Measure and Vasculitis Damage Index (VDI) was used for the clinical assessment of damage.

RESULTS

The mean±SD age of BD patients and control group was 38.19±10.99 and 33.65±7.29 years, respectively. The Physical Health score as well as most of SF-36 domains including Role Physical, Bodily Pain, General Health, Vitality, and Mental Health were significantly lower in BD patients compared with the control group (P<0.05). There was significant correlation between the Physical and Mental Health scores and most of SF-36 domains with disease activity and clinical symptoms including genital ulcers, ophthalmic and central nervous system (CNS) involvement (P<0.05). Significant correlation was only observed between VDI and Bodily Pain domain (P<0.05).

CONCLUSION

Quality of life is impaired in BD patients, and this impairment is related with disease severity. It seems that presence of genital ulcers, eye and CNS involvement lead to the impairment of QoL in BD patients. These results highlight the importance of nursing interventions in managing clinical symptoms in these patients.

Cigarette smoking and risk of primary systemic vasculitis: a propensity score matching analysis

Introduction

Considering limited data about the association between smoking and primary systemic vasculitides (PSV), present study aims to investigate smoking habit in PSV patients compared to healthy subjects as well as to examine the effect of smoking on clinical characteristics, disease activity and disease outcome in PSV patients.

Methodology

We included 126 patients diagnosed with PSV and 210 age- and sex-matched healthy controls. Demographic and clinical information and smoking history of patients and healthy controls were obtained by direct interview and questionnaire. Individuals who had smoked at least 100 cigarettes in their lifetime before the first symptom of vasculitis were classified as smokers; those who had never smoked or smoked less than 100 cigarettes in their lifetime were categorized as never smokers. Disease activity was evaluated by Birmingham Vasculitis Activity Score (BVAS). Disease outcome was assessed by vasculitis damage index (VDI) and the number of patients with disease in remission. Propensity score matching analyses (PSM) for reducing the heterogeneity between studied groups and calculating the actual effect of smoking in PSV was performed.

Results

No significant differences were observed in clinical manifestations and disease outcome of patients including VDI and the patients with disease in remission between ever and never smokers. However, disease activity according to BVAS in ever smokers was significantly higher than never smokers (P=0.020). PSM resulted in 82 patients with PSV, and 164 matched healthy persons with similar baseline characteristics. By multivariate logistic regression and after adjustment for age, sex, marital status and educational status, ever smoking was not significantly associated with an increased risk of PSV compared with never smoking.

Discussion and conclusion

Our study indicated a significant association between disease activity and smoking as well as a non-significant association between the clinical manifestations and disease outcome of PSV with smoking in Azeri population. Although further studies are needed to confirm these preliminary results, it seems that smoking may not be a significant risk factor for PSV.

Behçet syndrome: A great imitator

Behçet syndrome is considered to be a multisystemic vasculitis involving the skin, mucosa, eyes, joints, nervous system, cardiovascular system, and gastrointestinal system. The exact pathogenesis of the disease is unknown, but autoimmune factors are thought to play the main role. Vasculitis in Behçet syndrome can involve any kind and size of vessels, and this explains why the disease has the ability of multisystemic involvement. The commonest clinical presentation of Behçet syndrome is recurrent and painful mucocutaneous ulcerations known as aphthosis. The other clinical manifestations vary among patients and populations. The disease tends to be more severe in men. Ocular, vascular, and central nervous system involvements are the major causes of morbidity and mortality. Behçet syndrome is a mimicker of many diseases with its several faces and considered as one of the great imitators in dermatology.

Autoinflammatory Diseases and Physical Therapy

Autoinflammatory diseases (AIDs) constitute a group of clinical conditions, characterized by recurrent episodes of systemic inflammation, due to dysregulation of the innate immune system, without involving autoantibodies or antigen-specific T-cells. The patients exhibit recurrent episodes of fever with potentially serious complications and may have classic rheumatologic symptoms, including joint, skin, eye and muscle inflammation. Therefore, musculoskeletal problems and impaired quality of life can be anticipated as unavoidable consequences. In this regards any approach to ease the burden of symptoms and compensate the functional deficits are the main objectives of rehabilitation approach. For patients with inflammatory arthritis, physical therapy and rehabilitation methods have an important role in reducing joint pain and stiffness, preventing deformity, reconstructing muscle tissue and improving function. In order to justify the integration of rehabilitation approach in the management of AIDs and to determine the optimal protocols to use in this group of patients, well-designed, comprehensive, longitudinal, clinical trials using physical therapy centred outcomes are greatly needed.

Quality of life impairment in Behçet's disease and relationship with disease activity: a prospective study

Our aim was to prospectively investigate the impact of Behçet's disease (BD), disease activity, and clinical and demographic characteristics on different aspects of quality of life (QoL) measured by the short-form (SF)-36 QoL scale. We administered the SF-36 to 37 consecutive BD patients in different moments of disease activity, and to 23 healthy controls (HC). The eight subcategories of the SF-36 underwent statistical analysis for identifying differences and correlations. Compared to HC, BD patients showed significantly lower mean scores in all SF-36 QoL subscales except mental health and role-emotional. Females showed a poorer QoL compared to males. Disease activity evaluated by the BD Current Activity Form inversely correlated with physical functioning (ρ = -0.68, p < 0.0001), bodily pain (ρ = -0.68, p < 0.0001), role-physical (ρ = -0.64, p < 0.0001), vitality (ρ = -0.64, p < 0.0001), general health (ρ = -0.64, p < 0.0001), social functioning (ρ = -0.50, p = 0.0002), mental health (ρ = -0.48, p = 0.0004), and role-emotional (ρ = -0.40, p = 0.003). Mucosal, central nervous system (CNS), musculoskeletal and ocular manifestations were the main factors that negatively affected QoL in BD. For ocular disease, physical functioning was significantly impaired in patients with panuveitis compared to other ocular manifestations (p = 0.0002). Best-corrected visual acuity was inversely correlated with social functioning (ρ = -0.53, p < 0.0001), role-physical (ρ = -0.48, p < 0.0001), bodily pain (ρ = -0.46, p = 0.02), and mental health (ρ = -0.43, p < 0.0001). Patients with BD have a poorer QoL compared to HC, particularly for women, while the decline of QoL is closely related to the overall disease activity of BD. Single organ involvements may affect independently specific SF-36 subscales, especially mucosal, CNS, musculoskeletal, and ocular manifestations.

[Neurological and psychiatric disorders in Behҫet's disease]

The data of the literature on epidemiology, clinical manifestations, diagnosis and treatment of Behcet's disease are presented. Particular attention is paid to international recommendations (2014) on the classification, diagnostic criteria and treatment of neurological symptoms of Behҫet disease.

Prospective study of articular manifestations in Behçet's disease: five-year report

AIM

To evaluate different aspects of articular involvements (prevalence, types, relation to extra-articular manifestations, etc.) in Iranian patients with Behcet's disease (BD).

METHODS

In a prospective study, all patients with BD attending an outpatient BD clinic were enrolled. The type of articular involvements (peripheral or axial), involved joints, duration of attacks and their relation to extra-articular manifestations, human leukocyte antigen (HLA)-B5 and HLA-B27 were evaluated. Data analysis was done by using descriptive statistical indices such as mean and confidence interval. The comparisons were done by chi-square test.

RESULTS

In a 5-year period, 2312 patients were recruited. Musculoskeletal manifestations were recorded in 430 patients (190 without previous history of these involvements). The remaining 1882 patients showed no musculoskeletal involvements, of which 753 had past histories of musculoskeletal manifestations. The 5-year incidence rate was 18.6%, and the prevalence rate was 51.2%. History of previous musculoskeletal involvements has no effect in its new development (P = 0.2). Arthritis was the most common type of involvement (289/430, 67%). The most frequent pattern was monoarthritis (191/289, 66%), and the most frequent involved joints were knees (147/289, 50.9%). The arthritic attacks were unilateral in 82.4% of cases. Ankylosing spondylitis was seen in 44/430 (10.2%). There was no association between HLA-B5 or HLA-B27 and any type of musculoskeletal involvements (P > 0.5). Pseudofolliculitis was the only extra-articular manifestation related to arthritic attacks (P = 0.046).

CONCLUSION

Musculoskeletal involvement is a common manifestation of BD seen in more than half of patients. Acute knee monoarthritis was the most common pattern of articular involvement in BD.

Ultrasonographic Measurement of the Femoral Cartilage Thickness in Patients with Behçet's Disease

OBJECTIVE

To evaluate femoral cartilage thickness in patients with Behçet's disease (BD) by using ultrasonography.

METHODS

Thirty-one patients with BD (18 M, 13 F; mean age: 32.87 ± 8.5 years) and 31 age-, gender- and body mass index-matched healthy subjects were enrolled. Demographic features and medications of the patients were recorded. The femoral cartilage thicknesses of both knees were measured with a 7-12 MHz linear probe while subjects' knees were held in maximum flexion. Three mid-point measurements were taken from both knees: lateral femoral condyle (LFC), intercondylar area (ICA) and medial femoral condyle (MFC).

RESULTS

Cartilage measurements of BD patients were significantly thinner at the ICA (p = 0.009) and LFC (p = 0.007) on the left knee, and at the MFC on both sides (both p < 0.05). Left knee cartilage thickness value at MFC (p = 0.005) was decreased in BD patients with arthritis compared to the healthy control group.

CONCLUSION

These preliminary findings of decreased femoral cartilage thickness in BD patients with arthritis should be complemented with future studies. However, the possibility of early knee joint degeneration and eventual osteoarthritis in BD should also be kept in mind.

Epidemiology and management of neuropsychiatric disorders in Behçet's syndrome

Behçet's syndrome (BS) is a systemic, chronic, relapsing vasculitis, typically characterized by recurrent orogenital ulcers, ocular inflammation and skin manifestations; articular, vascular, gastroenteric and neurological involvement may also occur. Besides the other clinical features of BS, it seems relatively frequent that patients with BS develop a neurobehavioural syndrome, characterized by euphoria, bipolar disorders and paranoid attitudes, loss of insight/disinhibition, and indifference to their disease, defined as 'neuro-psycho-BS'. To date, the pathogenetic mechanism underlying neuro-psycho-BS has not been determined. It may be secondary to organic neurological involvement, or it may be related to poor quality of life and the relapsing course of the disease. Another engaging theory suggests that it could be related to the frequent observation of psychiatric symptoms during relapses or, in some cases, in the phases preceding reactivation of the disease; these elements suggest that psychiatric disorders in BS could represent a crucial element, whether a psychiatric subset or a distinct clinical feature of the disease. Moreover, it has been reported that cognitive impairment in BS can be seen with or without central nervous system involvement. Globally, psychiatric symptoms have been described as being multifaceted, ranging from anxiety disorders to depressive-bipolar disorders or to psychotic ones. In addition, some psychological characteristics of BS patients seem to predispose them to maladaptive stress management, which may lead to stress-related disorders, including anxiety and depression. Therefore, the aims of this review are to explore the epidemiology of neuro-psycho-BS by evaluating the relationship between the stress system and the multifaceted psychiatric manifestations in BS, and to summarize the therapeutic strategy used.

Elevated serum levels of calprotectin (MRP8/MRP14) in patients with Behçet's disease and its association with disease activity and quality of life

BACKGROUND

Behçet's disease (BD) is an inflammatory disease with multisystem chronic vasculitis. The disease is characterized by attacks of oral and genital ulcerations, skin lesions, arthritis, uveitis and deep vein thrombosis. The main histopathological feature is known to be vascular inflammatory change. Calprotectin (MRP8/MRP14) has been identified as an important alarmin that is expressed by activated phagocytes, granulocytes, monocytes and vascular endothelial cells, recognized by toll-like receptors, and induces a thrombogenic and inflammatory response in human microvascular endothelial cells.

AIM

We aimed to investigate the serum levels of calprotectin in patients with BD and its association with disease activity and quality of life.

MATERIALS AND METHODS

Forty-eight patients (25 males and 23 females) and 47 healthy controls (29 males and 18 females) were included to study. BD Current Activity Form (BDCAF) was used to assess the disease activity of patients with BD. Quality of life was assessed by using the Nottingham Health Profile (NHP). Depression and anxiety symptoms were assessed by using the Hospital Anxiety and Depression Scale (HADS). Serum level of calprotectin was determined using an ELISA kit. Results. Serum levels of calprotectin was significantly higher in patients with BD compared to healthy controls (p = 0.001). Serum levels of calprotectin did not correlate with the sores of BDCAF, NHP and HADS.

CONCLUSION

Calprotectin may play a significant role in the pathogenetic mechanisms of BD. Further insight into this area of research might provide opportunities to develop novel treatment strategies.

Validity and reliability of the Persian version of Behçet's disease quality-of-life (BD-QoL) questionnaire: a cross-cultural adaptation

The Leeds Behçet's disease quality-of-life (BD-QoL) questionnaire is a specific and valid measure which is applied in English-speaking patients. We conducted Persian adaptation of BD-QoL questionnaire. Between June and December 2012, 220 Iranian patients fulfilling International Study Group criteria for the diagnosis of BD attending the rheumatology clinics at Tehran University of Medical Sciences were enrolled. Bilingual translators undertook the forward translation and cross-cultural adaptation of the BD-QoL questionnaire. Back-translation was conducted, and this version was sent to the designer of the questionnaire and revised accordingly. SF-36 health survey, Iranian Behçet's disease dynamic activity measure (IBDDAM), and Behçet's Disease Current Activity Form (BDCAF) were other administered measures. The Varimax rotation method with Kaiser normalization defined 5 factors with eigenvalues greater than 1.0. Studied cases were comprised of 118 males (53.6 %) and 102 females (46.4 %). Mean age of the patients was 38.3 ± 11.3 years (range 16-73). The mean BD-QoL score was 10.3 ± 8.8. Test-retest reliability was high, and two time points were significantly correlated (Spearman's correlation coefficient of 0.75-0.84). Cronbach's α coefficient of 0.949 demonstrated the excellent internal consistency. These factors cumulatively explained 58.74 % of total variance. The ratio of first to second eigenvalue was 7.08, which underlined the undimensionality. The results revealed adapted BD-QoL scores had significant correlation with IBDDAM (correlation coefficient = 0.19, P value = 0.005) and BDCAF (correlation coefficient = 0.21, P value = 0.002). Conversely, no significant correlation between BD-QoL and SF-36 results was detected (P value = 0.078). The Persian version of BD-QoL was shown to be unidimensional, highly reliable, and adequate construct validity.

One-Year Period Prevalence of Oral Aphthous Ulcers and Oral Health-Related Quality of Life in Patients with Behçet's Disease

The aim of this study was to investigate the 1-year period prevalence of oral aphthous ulcers (OAUs) and their association with oral health-related quality of life (OHQOL) in patients with Behçet's disease (BD) and in the general population. In this cross-sectional study, 675 patients with Behçet's disease (BD group) and 1,097 males and females in the Japanese general population (control group) completed both questionnaires on their OAU status during the prior year and the General Oral Health Assessment Index (GOHAI). In the BD group, 84% of patients reported experiencing an OAU during the previous year, and the mean number of OAUs/year was 13. In the control group, 31% of individuals experienced an OAU during the previous year, and the mean number of OAUs/year was one. Multivariate analysis indicated that both BD patients (OR, 6.2; 95% CI, 4.8–8.0) and controls (OR, 2.6; 95% CI, 2.0–3.5) who had OAUs at least twice per year were more likely to have GOHAI scores below the norm than were controls who had fewer than two OAUs per year. The association between HLA-B∗51 and OAUs remains unknown. The presence of OAUs has a negative effect on the OHQOL of patients with BD.

Outcome measures used in clinical trials for Behçet syndrome: a systematic review

Behçet syndrome (BS) is a multisystem vasculitis that is most active during young adulthood, causing serious disability and significant impairment in quality of life. Differences in the disease course, severity, and organ involvement between patients, depending on the age at presentation and sex, makes it impossible to determine a single management strategy. The diversity and variability in the outcome measures used in clinical trials in BS makes it difficult to compare the results or inform physicians about the best management strategy for individual patients. There is a large unmet need to determine or develop validated outcome measures for use in clinical trials in BS that are acceptable to researchers and regulatory agencies. We conducted a systematic review to describe the outcomes and outcome measures that have been used in clinical trials in BS. This review revealed the diversity and variability in the outcomes and outcome measures and the lack of standard definitions for most outcomes and rarity of validated outcome tools for disease assessment in BS. This systematic literature review will identify domains and candidate instruments for use in a Delphi exercise, the next step in the development of a core set of outcome measures that are properly validated and widely accepted by the collaboration of researchers from many different regions of the world and from different specialties, including rheumatology, ophthalmology, dermatology, gastroenterology, and neurology.

Serum prolidase enzyme activity and oxidative status in patients with Behçet's disease

OBJECTIVES

To assess serum prolidase enzyme activity and oxidative stress in patients with Behçet's disease (BD).

METHODS

The study population consisted of BD patients (n = 42) and healthy participants (n = 29). BD patients were classified as active (n = 18) or inactive (n = 24) according to disease activity. Serum prolidase enzyme activity, total antioxidant status (TAS), total oxidative status (TOS), oxidative stress index (OSI), and malondialdehyde (MDA) levels were measured.

RESULTS

In BD patients with active disease, serum prolidase activity was significantly higher compared with the inactive and control participants. Serum prolidase activity was also significantly higher in all BD patients in comparison with controls. Serum prolidase activity was also positively correlated with OSI, C-reactive protein, and active BD. MDA, TOS, and OSI levels were all significantly higher in the BD group when compared with the healthy control participants. Serum TAS levels were significantly lower in BD patients in comparison with healthy controls.

CONCLUSION

High prolidase activity may indicate critical biological activities relevant to pathological events in BD, and this activity may be a biological indicator of disease. Further studies are needed to verify these findings.

Sexual dysfunction and depression in premenopausal women with mucocutaneous Behçet's disease

AIM

The aim of this study was to investigate depression and sexual dysfunction in female patients with mucocutaneous Behçet's disease (BD).

METHODS

Twenty-five consecutive, sexually active premenopausal female patients with mucocutaneous BD (mean age: 34.76 ± 4.61 SD years) followed at a rheumatology outpatient clinic were enrolled into the study. The control group consisted of 27 age-matched (mean age: 37.0 ± 4.6 SD years), sexually active, healthy volunteers. The Female Sexual Function Index (FSFI) and Beck Depression Inventory (BDI) were used for sexual and psychiatric assessment.

RESULTS

Depression was found in four of 27 (14.8%) in the control group and eight of 25 (32%) in the BD group (P = 0.01). The median total FSFI score for patients with BD was 21.85 (interquartile range [IQR]: 18.25-27.9) and for healthy controls, 27 (IQR 21.5-29.3; P = 0.03). Female sexual dysfunction was diagnosed in 14 of 25 (56%) in the BD group and in 11 of 27 (41%) in the control group (P = 0.27). The pain domain was significantly higher in the BD group at 5.6 (4.4-6.0) than in the control group at 4.4 (3.2-5.5; P = 0.03). None of the other domains (desire, arousal, lubrication, orgasm and satisfaction) of the BD and control groups were different. There were no statistically significant differences between the FSFI, BDI scores and presence of genital ulceration in the BD patients.

CONCLUSION

Depression and FSD were more common in the patients with BD than in the healthy subjects. This might have been a result of the depressive effect of chronic disease as well as BD and low androgen levels.

Cytokine gene variation is associated with depressive symptom trajectories in oncology patients and family caregivers

PURPOSE

Depressive symptoms are common in cancer patients and their family caregivers (FCs). While these symptoms are characterized by substantial interindividual variability, the factors that predict this variability remain largely unknown. This study sought to confirm latent classes of oncology patients and FCs with distinct depressive symptom trajectories and to examine differences in phenotypic and genotypic characteristics among these classes.

METHOD

Among 167 oncology outpatients with breast, prostate, lung, or brain cancer and 85 of their FCs, growth mixture modeling (GMM) was used to identify latent classes of individuals based on Center for Epidemiological Studies-Depression (CES-D) scores obtained prior to, during, and for four months following completion of radiation therapy. One hundred four single nucleotide polymorphisms (SNPs) and haplotypes in 15 candidate cytokine genes were interrogated for differences between the two largest latent classes. Multivariate logistic regression analyses assessed effects of phenotypic and genotypic characteristics on class membership.

RESULTS

Four latent classes were confirmed: Resilient (56.3%), Subsyndromal (32.5%), Delayed (5.2%), and Peak (6.0%). Participants who were younger, female, non-white, and who reported higher baseline trait and state anxiety were more likely to be in the Subsyndromal, Delayed, or Peak groups. Variation in three cytokine genes (i.e., interleukin 1 receptor 2 [IL1R2], IL10, tumor necrosis factor alpha [TNFA]), age, and performance status predicted membership in the Resilient versus Subsyndromal classes.

CONCLUSIONS

Findings confirm the four latent classes of depressive symptom trajectories previously identified in a sample of breast cancer patients. Variations in cytokine genes may influence variability in depressive symptom trajectories.

Does Behcet's disease associate with neuropathic pain syndrome and impaired well-being?

Previously peripheral neuropathy signs have been reported in inflammatory chronic diseases but the presence of neuropathic pain syndrome (NPS) in Behcet's disease (BD) is unclear. The aim of this study was to investigate the association of BD with NPS and impaired quality of life and sleep quality. A total of 111 patients diagnosed as BD and 52 healthy controls were included. Pain severity was assessed by visual analogue scale (VAS) in rest and during activity. The NPS was diagnosed according to the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) index. The well-being and sleep disturbances of the groups were evaluated with Psychological General Well-Being (PGWB) Scale and Pittsburg Sleep Quality Index (PSQI). Although there were no one with NPS in healthy controls, the proportion of NPS in patients with BD was 19.8 % (p = 0.001). The VAS scores both in activity and at rest were higher in BD (p < 0.001). There was statistically significant decrease in total PGWB score in BD patients compared to healthy controls (p < 0.001). And significant increase in LANSS score was observed in patients with BD compared to healthy controls (p = 0.000). The total LANSS scores showed significant positive correlation with PSQI scores (r = 0.322) and negative correlation with total PGWB scores (r = -0.672) in patients with BD. We observed a positive correlation between LANSS and VAS (rest and activity) scores (r = 0.44, r = 0.42 respectively). The NPS seems to be associated with BD which should be taken into consideration in patients with neuropathic signs. The quality of life (QoL) and quality of sleep of the patients with BD were found to be impaired and this may be due to the presence of NPS.

Pathophysiology of the Behçet's Disease

Behçet's disease (BD) is a multisystemic disease of unknown etiology characterized by chronic relapsing oral-genital ulcers and uveitis. Multiple systemic associations including articular, gastrointestinal, cardiopulmonary, neurologic, and vascular involvement are also observed in BD. Although the etiopathogenesis of the disease remains unknown, increased neutrophil functions such as chemotaxis, phagocytosis, and excessive production of reactive oxygen species (ROS), including superoxide anion, which may be responsible for oxidative tissue damage seen in BD, and also immunological alterations, T lymphocyte abnormalities in both subpopulation and function have been considered to be correlated with the etiopathogenesis of BD. There is some clinical evidence suggesting that emotional stress and hormonal alterations can influence the course and disease activity of BD.

Musculoskeletal Findings in Behcet's Disease

Behcet's disease is a multisystem disease characterized by recurrent oral and genital ulcers, relapsing uveitis, mucocutaneous, articular, gastrointestinal, neurologic, and vascular manifestations. Rheumatologic manifestations may also occur in Behcet's disease, and arthritis and arthralgia are the most common musculoskeletal findings followed by enthesopathy, avascular necrosis, myalgia, and myositis. Although the main pathology of Behcet's disease has been known to be the underlying vasculitis, the etiology and exact pathogenesis of the disease are still unclear. Musculoskeletal findings of Behcet's disease, the relationship between Behcet's disease and spondyloarthropathy disease complex, and the status of bone metabolism in patients with Behcet's disease were discussed in this paper.

Impact of Behçet's syndrome on health-related quality of life: influence of the type and number of symptoms

OBJECTIVE

To assess the overall impact of Behçet's syndrome (BS) on quality of life and the specific impact of the type and number of symptoms on the quality of life of adults with BS.

METHODS

A questionnaire was mailed to the 641 adult members of the Behçet's Syndrome Society in the UK. Participants provided information on socio-demographic characteristics, disease duration, current symptoms (mouth ulcers, genital ulcers, skin lesions, fatigue, joint problems, stomach/bowel problems, eye problems, pathergy reaction, headaches and other neurological problems), symptom control and quality of life (the EQ-5D index). Linear regression was used to test the associations of the type and number of symptoms with the EQ-5D index.

RESULTS

Of the 447 members, 400 who returned the questionnaires had a confirmed diagnosis of BS. Of them, 362 had information on the variables selected for this analysis (76% females and 94% white British). The mean EQ-5D index was 0.47 (S.D. 0.38). Of the 10 symptoms assessed, joint problems had the strongest impact on quality of life, followed by neurological problems, pathergy reaction and stomach/bowel problems (adjusted coefficients of -0.15, -0.13, -0.11 and -0.18, respectively). Furthermore, the number of symptoms was significantly related to the EQ-5D index after adjustment for socio-demographic characteristics, disease duration and symptom control. The EQ-5D index decreased by -0.05 U for every additional symptom reported.

CONCLUSIONS

BS has a considerable impact on quality of life. Both the type and number of symptoms affect the quality of life of adults with BS.

The Behcet's Disease Quality of Life: reliability and validity of the Korean version

PURPOSE

The Behcet's Disease Quality of Life (BD-QoL) is a BD-specific measure developed in the UK. The aim of this study was to adapt the BD-QoL for use in Korea.

PATIENTS AND METHODS

The translation was based on the guidelines for cross-cultural adaptation. A total of 201 Korean patients with BD participated in this study. To evaluate the psychometric properties, internal consistency and test-retest reliability were used. Factor analysis was performed to examine the construct validity. To provide further evidence for validity, the correlation of BD-QoL with the Clinical Activity Form for Korean Patients with BD (BDCAF-K) and the Center for Epidemiologic Studies-Depression (CES-D) scales was assessed.

RESULTS

The Korean version had high internal consistency (Cronbach's alpha, 0.93) and test-retest reliability (r = 0.835). Factor analysis of the questionnaire revealed one interpretable factor as a general health-related quality of life factor. The Korean version significantly correlated with scores of CES-D (r = 0.749, p = 0.000), self-rating scale of well-being over the past 28 days (r = 0.446, p = 0.000), and BDCAF-K score (r = 0.502, p = 0.000).

CONCLUSION

Adaptation of the BD-QoL for use in Korea was successful. Together with the BDCAF-K, it may be a valuable tool for assessing the influence of interventions in BD patients and outcome in clinical trials.

[Skeletal manifestations in Behçet's disease. A report of 79 cases]

PURPOSE

Our aim is to describe the skeletal manifestations of Behcet's disease (BD) among young adults in a military population.

METHODS

We conducted a retrospective study of 176 patients with BD who were followed between 1980 and 2005. All the patients fulfilled the international study group on Behcet's disease diagnostic criteria.

RESULTS

Rheumatic manifestations were noticed in 79 out of 176 patients (45%), ranking second after the skin and mucosal manifestations of the disease. Articular manifestations were the first disease manifestation in 16.5% of the patients. Inflammatory arthralgias were the most common manifestation and observed in 81%, interesting mainly the large lower limb joints. Disease course was acute in most of the patients. Arthritis was less common: oligoarthritis (7.5%), monoarthritis (6.5%) and polyarthritis (5%). Axial involvement was also noted: spine pain in 29%, isolated sacroiliitis in 7.5%, and definite ankylosing spondylitis in 5%.

CONCLUSION

Joint involvement is common in BD and could be the first manifestation of the disease. Most of the patients present with inflammatory arthralgias of the large lower limb joints. Disease course is usually favourable, spontaneously or with treatment. However, in our study population, skeletal manifestations were responsible for significant disability.